VA/DOD CLINICAL PRACTICE GUIDELINES - MANAGEMENT AND REHABILITATION OF POST-ACUTE MILD TRAUMATIC BRAIN INJURY - PROVIDER SUMMARY
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VA/DoD Clinical Practice Guidelines
Management and Rehabilitation of
Post-Acute Mild Traumatic
Brain Injury
Provider Summary
Version 3.0 | 2021
VA/DoD CLINICAL PRACTICE GUIDELINE FOR
THE MANAGEMENT AND REHABILITATION OF
POST-ACUTE MILD TRAUMATIC BRAIN INJURY
Department of Veterans Affairs
Department of Defense
Provider Summary
QUALIFYING STATEMENTS
The Department of Veterans Affairs and the Department of Defense guidelines are based upon the best
information available at the time of publication. They are designed to provide information and assist
decision making. They are not intended to define a standard of care and should not be construed as one.
Neither should they be interpreted as prescribing an exclusive course of management.
This Clinical Practice Guideline is based on a systematic review of both clinical and epidemiological
evidence. Developed by a panel of multidisciplinary experts, it provides a clear explanation of the logical
relationships between various care options and health outcomes while rating both the quality of the
evidence and the strength of the recommendation.
Variations in practice will inevitably and appropriately occur when clinicians take into account the needs of
individual patients, available resources, and limitations unique to an institution or type of practice. Every
healthcare professional making use of these guidelines is responsible for evaluating the appropriateness of
applying them in the setting of any particular clinical situation.
These guidelines are not intended to represent Department of Veterans Affairs or TRICARE policy. Further,
inclusion of recommendations for specific testing and/or therapeutic interventions within these guidelines
does not guarantee coverage of civilian sector care. Additional information on current TRICARE benefits
may be found at www.tricare.mil by contacting your regional TRICARE Managed Care Support Contractor.
Version 3.0 – 2021
VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Table of Contents
Introduction ......................................................................................................................................... 1
Recommendations .................................................................................................................................. 1
Algorithm ................................................................................................................................................ 5
Module A: Initial Presentation (>7 Days Post-injury) ............................................................................... 6
Module B: Management of Symptoms Persisting >7 Days After Mild Traumatic Brain Injury .............. 7
Reference Guide for Providers, Veterans, and Families: Accessing Mental Health Services after
Traumatic Brain Injury ................................................................................................................... 10
Clinical Symptom Management ............................................................................................................. 13
A. Contents ............................................................................................................................................. 13
B. Introduction ....................................................................................................................................... 13
C. Medication ......................................................................................................................................... 14
D. Co-occurring Conditions .................................................................................................................... 14
E. Headache ........................................................................................................................................... 15
F. Dizziness and Disequilibrium ............................................................................................................. 15
G. Visual Symptoms................................................................................................................................ 18
H. Fatigue.........................................................................................................................................19
I. Sleep Disturbance .............................................................................................................................. 19
J. Cognitive Symptoms .......................................................................................................................... 20
K. Persistent Pain ................................................................................................................................... 21
L. Hearing Difficulties ............................................................................................................................ 22
M. Other Symptoms ................................................................................................................................ 23
Scope of the CPG ................................................................................................................................... 24
Methods................................................................................................................................................ 24
Guideline Work Group........................................................................................................................... 26
Patient-centered, Stepped Care, and a “Whole Health” Orientation ...................................................... 27
Shared Decision Making ........................................................................................................................ 27
References ............................................................................................................................................ 28
VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Introduction
The Department of Veterans Affairs (VA) and Department of Defense (DoD) Evidence-Based Practice Work
Group (EBPWG) was established and first chartered in 2004, with a mission to advise the Health Executive
Committee (HEC) “… on the use of clinical and epidemiological evidence to improve the health of the
population …” across the Veterans Health Administration (VHA) and Military Health System (MHS), by
facilitating the development of clinical practice guidelines (CPGs) for the VA and DoD populations.(1)
Development and update of VA/DoD CPGs is funded by VA Evidence Based Practice, Office of Quality and
Patient Safety. The system-wide goal of evidence-based CPGs is to improve patient health and well-being.
In February 2016, the VA and DoD published a CPG for the Management of Concussion-mild Traumatic
Brain Injury (2016 VA/DoD mTBI CPG), which was based on evidence reviewed through March 2015. Since
the release of that CPG, a growing body of literature has expanded the evidence base and understanding
of mild traumatic brain injury (mTBI). Consequently, a recommendation to update the 2016 VA/DoD mTBI
CPG was initiated in 2019.
This CPG provides an evidence-based framework for the management and rehabilitation of patients with
symptoms attributed to mTBI toward improving clinical outcomes. Successful implementation of this
CPG may facilitate:
· Assessing the patient’s condition and collaborating with the patient, family, and caregivers to
determine optimal management of patient care
· Emphasizing the use of patient-centered care using individual risk factors and event history
· Minimizing preventable complications and morbidity
· Optimizing individual health outcomes and quality of life
The full VA/DoD mTBI CPG, as well as additional toolkit materials including a pocket card and provider
summary, can be found at: https://www.healthquality.va.gov/index.asp.
Recommendations
The following evidence-based clinical practice recommendations were made using a systematic approach
considering four domains as per the GRADE approach (see Appendix A in the full VA/DoD mTBI CPG).
These domains include: confidence in the quality of the evidence, balance of desirable and undesirable
outcomes (i.e., benefits and harms), patient values and preferences, and other implications (e.g., resource
use, equity, acceptability).
The target population for these recommendations is patients with symptoms attributed to mTBI in the
post-acute phase (see Guideline Population in the full VA/DoD mTBI CPG).
June 2021 Page 1 of 31VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Table 1. Recommendations
Sub-
Topic topic # Recommendation Strengtha Categoryb
We suggest a primary care (as opposed to specialty care),
symptom-focused approach in the evaluation and management Reviewed,
1. Weak for
Setting of Care
of the majority of patients with symptoms attributed to mild Amended
traumatic brain injury.
There is insufficient evidence to recommend for or against
specialized treatment programs to improve morbidity, function, Neither for nor Reviewed, New-
2.
and return to work in patients with persistent symptoms against replaced
attributed to mild traumatic brain injury.
For patients with new symptoms that develop more than 30 days
Not reviewed,
3. after mild traumatic brain injury, we suggest a symptom-specific Weak for
Amended
evaluation for non-mild traumatic brain injury etiologies.
We suggest against using the following tests to establish the
Diagnosis and Assessment
diagnosis of mild traumatic brain injury or direct the care of
patients with symptoms attributed to mild traumatic brain injury: Reviewed,
4. Weak against
a. Neuroimaging Amended
b. Serum biomarkers
c. Electroencephalogram
We suggest against using computerized post-concussive
Reviewed,
5. screening batteriesa for routine diagnosis and care of patients Weak against
Amended
with symptoms attributed to mild traumatic brain injury.
We suggest against performing comprehensive
Reviewed, Not
6. neuropsychological/cognitive testing during the first 30 days Weak against
changed
following mild traumatic brain injury.
Mild Traumatic Brain Injury and
Future Neurocognitive Decline
When counseling patients about the long-term effects of mild
traumatic brain injury, there is insufficient evidence to state that Neither for nor Reviewed, New-
7.
single or repeated mild traumatic brain injury increases their risk against added
of future neurocognitive decline.
When counseling patients about the long-term effects of mild
traumatic brain injury, there is insufficient evidence to state that
demographic, injury-related clinical, and management factors Neither for nor Reviewed, New-
8.
increase the risk of future neurocognitive decline in patients with against added
symptoms attributed to single or repeated mild traumatic brain
injury.
a E.g., Automated Neuropsychological Assessment Metrics (ANAM), Neuro-Cognitive Assessment Tool (NCAT), and Immediate
Post-Concussion Assessment and Cognitive Testing (ImPACT)
June 2021 Page 2 of 31VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Sub-
Topic topic # Recommendation Strengtha Categoryb
Effects of Mild Traumatic Brain
Injury Etiology on Treatment
We suggest against adjusting outcome prognosis and treatment Reviewed, New-
9. Weak against
strategy based on mechanism of injury. replaced
We suggest that patients with symptoms attributed to mild
a. Cognitive Symptoms
traumatic brain injury who present with memory, attention, or
executive function problems despite appropriate management of Reviewed,
10. Weak for
other contributing factors (e.g., sleep, pain, behavioral health, Amended
headache, disequilibrium) should be referred for a short trial of
clinician-directed cognitive rehabilitation services.
Symptom-based Treatments of Mild Traumatic Brain Injury
We suggest against the use of self-administered computer
Reviewed, New-
11. training programs for the cognitive rehabilitation of patients with Weak against
added
symptoms attributed to mTBI.
We suggest that patients with symptoms attributed to mild
b. Behavioral
traumatic brain injury who present with behavioral health
Symptoms
conditions, including posttraumatic stress disorder, substance use
Reviewed,
12. disorders, and mood disorders, be evaluated and managed the Weak for
Amended
same whether they have had mild traumatic brain injury or not,
according to the relevant existing VA/DoD clinical practice
guidelines.
Proprioceptive Symptoms
c. Vestibular and
We suggest that patients with persistent symptoms of dizziness
and imbalance attributed to mild traumatic brain injury be Reviewed, New-
13. Weak for
offered a trial of specific vestibular rehabilitation and replaced
proprioceptive therapeutic exercise.
There is insufficient evidence to suggest for or against the use of
Symptoms
d. Visual
any particular modality for the treatment of visual symptoms
Neither for nor Reviewed,
14. attributed to mild traumatic brain injury such as diplopia,
against Amended
accommodation or convergence deficits, visual tracking deficits
and/or photophobia.
June 2021 Page 3 of 31VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Sub-
Topic topic #
Mild Traumatic Brain Injury (cont.) Recommendation Strengtha Categoryb
Symptom-based Treatments of
e. Tinnitus
There is no evidence to suggest for or against the use of any
Neither for nor Reviewed,
15. particular modality for the treatment of tinnitus attributed to
against Amended
mild traumatic brain injury.
f. Exertion-induced
Symptoms
There is insufficient evidence to recommend for or against
Neither for nor Reviewed, New-
16. treatments for exertion-induced symptoms/symptom clusters
against added
attributed to mild traumatic brain injury.
There is insufficient evidence to recommend for or against the
use of any of the following interventions for the treatment of
Interventions with Insufficient Evidence
patients with symptoms attributed to mild traumatic brain injury:
a. Complementary and
Integrative Health
a. Acupuncture
b. Tai chi
c. Meditation Neither for nor Reviewed, New-
17.
d. Mindfulness against added
e. Yoga
f. Massage
g. Chiropractic therapy
h. Cranial electrotherapy stimulation (CES)
i. Sensory deprivation tanks
Oxygen Therapy
b. Hyperbaric
We recommend against the use of hyperbaric oxygen therapy for
Reviewed, New-
18. the treatment of patients with symptoms attributed to mild Strong against
added
traumatic brain injury.
Insufficient Evidence (cont.)
c. Repetitive Transcranial
Magnetic Stimulation
Interventions with
We suggest against the use of repetitive transcranial magnetic
Reviewed, New-
19. stimulation for the treatment of patients with symptoms Weak against
added
attributed to mild traumatic brain injury.
a For additional information, see Grading Recommendations in the full VA/DoD mTBI CPG.
b For additional information, see Recommendation Categorization and Appendix D in the full VA/DoD mTBI CPG.
June 2021 Page 4 of 31VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Algorithm
This CPG’s algorithm is designed to facilitate understanding of the clinical pathway and decision-making
process used in managing patients with symptoms attributed to mTBI. This algorithm format represents a
simplified flow of the management of patients with symptoms attributed to mTBI and helps foster efficient
decision making by providers. It includes:
· An ordered sequence of steps of care
· Decisions to be considered
· Recommended decision criteria
· Actions to be taken
The algorithm is a step-by-step decision tree. Standardized symbols are used to display each step, and
arrows connect the numbered boxes indicating the order in which the steps should be followed.(2)
Sidebars provide more detailed information to assist in defining and interpreting elements in the boxes.
Shape Description
Rounded rectangles represent a clinical state or condition
Hexagons represent a decision point in the process of care, formulated as a question that
can be answered “Yes” or “No”
Rectangles represent an action in the process of care
Ovals represent a link to another section within the algorithm
For alternative text descriptions of the algorithm, please refer to Appendix K in the full VA/DoD mTBI CPG.
June 2021 Page 5 of 31VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Module A: Initial Presentation (>7 Days Post-injury)
Abbreviations: DoD: Department of Defense; mTBI: mild traumatic brain injury; TBI: traumatic brain injury
June 2021 Page 6 of 30VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Module B: Management of Symptoms Persisting >7 Days After Mild Traumatic Brain
Injury
Abbreviations: CPG: clinical practice guideline; DoD: Department of Defense; TBI: traumatic brain injury; mTBI: mild traumatic brain
injury; PTSD: posttraumatic stress disorder; SUD: substance use disorder; VA: Department of Veterans Affairs
June 2021 Page 7 of 30VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Sidebar 1: Potential Indicators for Immediate Referral
· Declining level of consciousness/impaired alertness
· Declining neurological exam/focal neurological symptoms
· Pupillary asymmetry
· Seizures
· Repeated vomiting
· Motor or sensory deficits
· Double vision
· Worsening headache
· Slurred speech
· Marked change in behavior or orientation
Sidebar 2: Classification of TBI Severitya
Criteria Mild Moderate Severe
b
Structural imaging (see Recommendation 4) Normal Normal or abnormal Normal or abnormal
Loss of consciousness 0 – 30 min >30 min and 24 hours
c
Alteration of consciousness/mental state up to 24 hours >24 hours; severity based on other criteria
Post-traumatic amnesia 0 – 1 day >1 and 7 days
Glasgow Coma Scale (best available score in
13 – 15 9 – 12VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Sidebar 4: Symptom Attributes
· Duration, onset, and location of symptom
· Previous episodes, treatment, and response
· Patient perception of symptom
· Impact on functioning
· Factors that exacerbate or alleviate symptom
Sidebar 5: Relevant VA/DoD CPGs
· VA/DoD Clinical Practice Guideline for the Management of Chronic Insomnia Disorder and Obstructive Sleep
Apnea. Available at: https://www.healthquality.va.gov/guidelines/CD/insomnia/index.asp
· VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder. Available at:
https://www.healthquality.va.gov/guidelines/MH/mdd/
· VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. Available at:
https://www.healthquality.va.gov/guidelines/Pain/cot/
· VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress
Reaction. Available at: https://www.healthquality.va.gov/guidelines/MH/ptsd/
· VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders. Available at:
https://www.healthquality.va.gov/guidelines/MH/sud/
· VA/DoD Clinical Practice Guideline for the Primary Care Management of Headache. Available at:
https://www.healthquality.va.gov/guidelines/Pain/headache/
· VA/DoD Clinical Practice Guideline for the Management of Chronic Multisymptom Illness. Available at:
https://www.healthquality.va.gov/guidelines/MR/cmi/
· VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide. Available
at: https://www.healthquality.va.gov/guidelines/MH/srb/
Sidebar 6: Early Intervention
· Integrate patient and caregiver needs and preferences into assessment and treatment
· Provide information and education on symptoms and expected recovery
· Provide reassurance on expectation of positive recovery
· Educate about prevention of further injury
· Empower patient for self-management
· Consider teaching relaxation and stress management techniques as needed
· Recommend limiting use of caffeine/nicotine/alcohol
· Encourage monitored progressive return to normal duty/work/activity/exercisea
· Discuss need for consistency with healthy nutrition, exercise, and sleep habits
· Provide information regarding the National Suicide Prevention Lifeline (1-800-273-8255) if appropriate
a Provider resources for progressive return to activity (PRA) are available at:
https://www.health.mil/About-MHS/OASDHA/Defense-Health-Agency/Research-and-Development/Traumatic-Brain-Injury-
Center-of-Excellence/Provider-Resources
Sidebar 7: Case Management
Case managers may:
· Provide coordination of care as outlined in the individualized treatment plan (referrals, authorizations,
appointments/reminders)
· Provide advocacy and support for Veteran/Service Member and caregivers
· Reinforce early interventions and education
· Address psychosocial issues (financial, family, housing, or school/work)
· Connect patient to available resources
June 2021 Page 9 of 30VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Reference Guide for Providers, Veterans, and Families: Accessing Mental Health
Services after Traumatic Brain Injury
Table 2. Reference Guide for Providers, Veterans, Families: Accessing Mental Health Services
after Traumatic Brain Injury
Note: This table was developed by the Mental Health Workgroup of the VHA Committee on the Care of Veterans
with Traumatic Brain Injury, February 2021.
Question or Mental
Health Need Mental Health Reference Materials and Websites to Learn More
Military Culture Training for Health Care Professionals: Treatment Resources,
Military Culture Training Prevention & Treatment
VA TMS 2.0 course # 19335 (internal VA training site)
Immediately phone mental health provider in your VA or engage PCMHI in your clinic
Current suicidal ideations
for assistance in evaluating the patient straightaway. Do not leave the patient
with patient in provider’s
unattended while accessing mental health care. Additional guidance can be obtained
office
by calling the Veterans Crisis Line at 1-800-273-8255.
Learning more about how
to evaluate for suicidal
https://www.mirecc.va.gov/visn19/education/products.asp
ideas and general warning
signs
Preventing suicide or self-directive violence is critical in the prevention of suicide in
Lethal Means Safety and
Veterans. One aspect is the prevention of lethal means.
Suicide prevention
https://www.mirecc.va.gov/lethalmeanssafety/index.asp
Learning how to discuss lethal means safety with Veterans and their families is critical
Lethal Means Safety to the prevention of suicide. This site provides training in how to have these critical
Training for providers discussions.
https://www.mirecc.va.gov/visn19/lethalmeanssafety/counseling/
Preventing suicide and evaluation for risk is critical. This website describes VHA efforts
Suicide Risk Screening and towards screening evaluation, risk assessment, and education on different levels of
Evaluation for providers risk stratification with evidence-based tools.
https://dvagov.sharepoint.com/sites/ECH/srsa (internal Sharepoint site for VA staff)
To refer a Veteran in clinic
for treatment of mental
PACT providers should turn first to their PCMHI, if available. If not, consultation to the
health symptoms beyond
mental health Service Line for referrals.
the comfort/scope of
primary care interventions
General Facts on TBI
exposures in OIF/OEF/OND
Veterans: includes
https://www.polytrauma.va.gov/understanding-tbi/
information on assessments
and treatment
recommendations
Neuropsychiatric The website contains information for Veterans, families, and providers.
Manifestations after TBI https://www.mirecc.va.gov/visn6/TBI_education.asp
Substance Use after TBI and
https://www.mirecc.va.gov/visn19/education/products.asp
Risk Reduction
Teaching Tools for trainees
on understanding
https://www.mirecc.va.gov/visn6/Tools-Tips.asp
neuroanatomy and
neuropsychiatry
June 2021 Page 10 of 30VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Question or Mental
Health Need Mental Health Reference Materials and Websites to Learn More
PTSD Guides and
https://www.ptsd.va.gov/professional/index.asp
references for providers
PTSD Guides and
references for Veterans and https://www.ptsd.va.gov/family/effects_ptsd.asp
families
Common Post-deployment
Symptom Education Guides https://www.mirecc.va.gov/visn6/Readjustment.asp
for patients
Overview of PTSD and
https://www.ptsd.va.gov/professional/treat/cooccurring/research_violence.asp
violence towards others
Evaluating risk of violence
towards others in context https://www.ptsd.va.gov/professional/treat/cooccurring/assessing_risk_violence.asp
of PTSD
Epidemiological Data on
Common Diagnoses and https://www.publichealth.va.gov/epidemiology/reports/oefoifond/health-care-
numbers of Veterans utilization/index.asp
treated post-deployment
PTSD Consultation Services
with the National Center for PTSDconsult@va.gov
PTSD
General Facts on Chronic TMS 2.0 (internal VA training site)
Pain in OIF/OEF/OND
Veterans Course # 13260: chronic pain
Caregiver Education This site provides extensive education for caregivers of Veterans with many chronic
Facts and handouts on disease processes.
multiple medical conditions https://www.caregiver.va.gov/publications_resources_topic.asp
This site provides extensive resources for Veteran caregivers and families on a wide
Military-Veteran Caregiver variety of psychosocial and medical issues.
and Family Education
https://psycharmor.org/caregivers/
CPG for Patients at Risk for
https://www.healthquality.va.gov/guidelines/MH/srb/
Suicide
CPG for PTSD https://www.healthquality.va.gov/guidelines/MH/ptsd/
CPG for mild TBI https:https://www.healthquality.va.gov/guidelines/Rehab/mtbi/
CPG for Opioid Therapy for
https://www.healthquality.va.gov/guidelines/Pain/cot/
Chronic Pain
Consensus Conference
Recommendations for https://www.mirecc.va.gov/docs/visn6/Report_Consensus_Conf_Practice_Recomme
Treating patients with mild nd_TBI_PTSD_Pain.pdf
TBI, PTSD, and Pain
Apps for the management of multiple mental health conditions and TBI- related
VA Mobile Phone APPs symptoms, including the new COVID coach app.
https://mobile.va.gov/appstore
Website supports for
managing stress in https://www.cstsonline.org/resources/resource-master-list/coronavirus-and-
providers, Veterans, emerging-infectious-disease-outbreaks-response
community, and families in
times of infectious disease https://www.ptsd.va.gov/covid/index.asp
outbreaks
June 2021 Page 11 of 30VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Question or Mental
Health Need Mental Health Reference Materials and Websites to Learn More
This website has resources for managing stress in the pandemic. It contains guidance
Managing general stress in for the general public, for health care workers, and for employers and community
times of COVID-19 leaders.
https://www.ptsd.va.gov/covid/index.asp
Managing PTSD in the This website contains recorded lectures from the National Center for PTSD on
context of the COVID-19 managing PTSD in the COVID-19 pandemic.
pandemic https://www.ptsd.va.gov/professional/consult/lecture_series.asp
This Center for Disease Control (CDC) website contains multiple resources for
Coping strategies for
identifying and managing the mental health toll of COVID-19. It includes resources for
building resilience in COVID-
personal life and for the workplace. https://www.cdc.gov/coronavirus/2019-
19
ncov/daily-life-coping/stress-coping/index.html
Abbreviations: CDC: Centers for Disease Control and Prevention; CPG: clinical practice guideline; COVID-19: coronavirus disease
2019; OEF: Operation Enduring Freedom; OIF: Operation Iraqi Freedom; OND: Operation New Dawn; PACT: patient-aligned care
team; PCMHI: Primary Care Mental Health Integration Team; PTSD: posttraumatic stress disorder; TBI: traumatic brain injury; TMS:
Talent Management System; VA: Department of Veterans Affairs; VHA: Veterans Health Administration
June 2021 Page 12 of 30VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Clinical Symptom Management
A. Contents
This section (also included in Appendix G in the full VA/DoD mTBI CPG) serves as a reference guide for
symptoms most commonly occurring after a history of mTBI. VA/DoD CPGs on many of these symptoms
are available to help guide providers (available at www.healthquality.va.gov). Symptom treatment is not
based on the underlying mechanism of injury; instead, it is based on standardized clinical practice for that
disorder or diagnosis. Given the complexities of war-related injury, there can be many co-occurring
conditions. There is a lack of randomized controlled trials (RCTs) to guide assessment and treatment of
these conditions; therefore, providers must use clinical judgment and refer to other VA/DoD CPGs.
B. Introduction
The emergence of behavioral symptoms after mTBI can depend on many factors including pre-injury
psychosocial function and/or pre-existing illnesses or conditions, genetic predisposition to neurobehavioral
disorders, injury factors, and post-injury psychosocial and health factors. The nature and severity of
symptoms, as ascertained in a thorough medical history, should be determined to optimally choose
appropriate treatments. A comprehensive treatment plan that integrates psychosocial and pharmacologic
interventions is recommended, as there is a paucity of strong evidence for a singular treatment that
specifically targets symptoms in this population.
There is a complex relationship among symptoms attributed to mTBI (e.g., headache, sleep disturbances,
cognition, mood). It is clinically reasonable to expect that alleviating and improving one symptom may lead
to an improvement in other symptoms and symptom clusters. The presence of co-occurring mental health
problems (e.g., major depressive disorder [MDD], anxiety disorders, posttraumatic stress disorder [PTSD],
substance use disorders [SUD]), that may or may not be etiologically related to the mTBI, should be
comprehensively managed.
There are no specific U.S. Food and Drug Administration (FDA) approved pharmaceutical agents for the
treatment of post-concussive neurological or behavioral symptoms. Management of behavioral and
mental health conditions following mTBI should be guided by CPGs for behavioral conditions (with or
without mTBI) and the guidance from the mental health field.
See guidance such as:
· VA/DoD Clinical Practice Guidelines Homepage - www.healthquality.va.gov
· VA National Center for PTSD: Traumatic Brain Injury and PTSD -
https://www.ptsd.va.gov/professional/treat/cooccurring/tbi_ptsd_vets.asp
· Psychological Health Center of Excellence (PHCoE) VA/DoD Clinical Practice Guidelines and Clinical
Support Tools -
https://www.pdhealth.mil/clinical-guidance/clinical-practice-guidelines-and-clinical-support-tools
· VA Health Services Research and Development: Evidence-based Synthesis Program -
www.hsrd.research.va.gov/publications/esp/
The Work Group neither reviewed nor endorses the accuracy or clinical utility of other provider resources.
June 2021 Page 13 of 30VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
C. Medication
Treatments for difficulties that arise proximately to a concussion should be symptom-based and not
specific to the historical traumatic event. Sound clinical judgment with a thorough clinical history, targeted
physical exam, and any needed laboratory testing appropriate to the condition are always prudent before
prescribing any treatment. If pharmacologic intervention is being considered, following established
recommended dosing guidelines for the specific symptoms or conditions is prudent.
Considerations in using medication for treatment of symptoms after brain injury include:
· Avoid medications that lower the seizure threshold (e.g., bupropion, traditional antipsychotic
medications) or those that can cause confusion (e.g., lithium, benzodiazepines, anticholinergic
agents).
· Before prescribing medications, rule out social factors (e.g., abuse, neglect, caregiver conflict,
environmental issues).
· Unless side effects prevail, give full therapeutic trials at maximal tolerated doses before
discontinuing a medication trial. Under-treatment is common.
· Some patients with symptoms attributed to mTBI can be more sensitive to side effects. Watch
closely for toxicity and drug-drug interactions. Assess regularly for side effects.
· Limit quantities of medications with high risk for suicide. The suicide rate in individuals who have
sustained a TBI is higher than in the general population.
· Educate patients and family/caregivers to avoid the use of alcohol or other illicit drugs with the
medications.
· Minimize caffeine and avoid herbal or dietary supplements such as “energy” products, as some
contain agents that cross-react with prescribed medications (e.g., use with certain psychiatric
medications may lead to a hypertensive crisis).
D. Co-occurring Conditions
a. Clinical Guidance
Assess individuals in a primary care setting. Typical screening instruments for co-occurring mental health
diagnoses or symptoms include the Columbia Suicide Severity Rating Scale (C-SSRS), Patient Health
Questionnaire (PHQ-2 or PHQ-9), the Generalized Anxiety Disorder Scale (GAD-2 or GAD-7), Alcohol Use
Disorders Identification Test-Concise (AUDIT-C), and the PTSD Checklist (PCL-5). While these instruments
do not diagnose individuals with MDD, anxiety, SUD, or PTSD, they serve to identify individuals who
require further assessment. Many of these screening instruments have links to access them within the
electronic health record.
It is always critical that the evaluation of individuals with persistent symptoms attributed to mTBI includes
an assessment for suicidal and homicidal ideations. If an individual’s history or current distress suggests
any suicidal ideas, intent, past attempts, or worsening psychiatric symptoms, consider consulting with, or
referring to, a behavioral health provider. Many institutions have mental health teams embedded in
primary care for same-day access or have a fast-track referral system for immediate interventions. For
individuals who present with an existing and chronic psychiatric disorder, refer to behavioral health
services for further follow-up/treatment if indicated.
June 2021 Page 14 of 30VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Individuals with persistent symptoms attributed to mTBI should be re-evaluated for emerging or
worsening co-occurring mental health disorders, as clinically indicated.
In individuals with persistent post-concussive symptoms that have been refractory to treatment,
consideration should be given to other factors that may be contributing, including unidentified mental
health disorders, lack of psychosocial support, negative illness expectations, and compensation/litigation
issues. Clinicians should be very careful with any communications with patients regarding possible
attributions of physical symptoms to any of these causes and should follow clinical guidelines for the
management of persistent unexplained symptoms.
The VA/DoD CPG website has the following guidelines to assist with the management of co-occurring
mental health symptoms:
· Suicideb
· MDDc
· PTSDd
· SUDe
E. Headache
a. Background
Post-traumatic headaches (PTH) are very common, occurring in 25-78% of individuals following mTBI.(4)
They are more frequent in individuals with mild versus moderate or severe TBI,(5) including having a
negative correlation between the duration of unconsciousness and incidence of headache in moderate to
severe TBI.(6) Posttraumatic headache most frequently resembles tension-type or migraine headaches and
can be exacerbated by very mild physical or mental exertion.
For a much more detailed analysis of PTH and guidance on how to manage patients, see the VA/DoD CPG
for the Primary Care Management of Headache (2019).f
F. Dizziness and Disequilibrium
a. Background
Dizziness and disequilibrium are common symptoms that individuals present with in the primary care
settings and may be related to mTBI. They have a range of causes and can be broadly organized into the
following disorders: inner ear disorders (peripheral vestibular disorders), central nervous system disorders,
psychological disorders, musculoskeletal disorders, and (commonly) idiopathic disorders.
b See the VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for Suicide. Available at:
https://www.healthquality.va.gov/guidelines/MH/srb/
c See the VA/DoD Clinical Practice Guideline for the Management Major Depressive Disorder. Available at:
https://www.healthquality.va.gov/guidelines/MH/mdd/
d See the VA/DoD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Reaction.
Available at: https://www.healthquality.va.gov/guidelines/MH/ptsd/
e See the VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorder. Available at:
https://www.healthquality.va.gov/guidelines/MH/sud/
f See the VA/DoD Clinical Practice Guideline for the Primary Care Management of Headache. Available at:
https://www.healthquality.va.gov/guidelines/Pain/headache/
June 2021 Page 15 of 30VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
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b. Assessment
1. Physical Examination
In individuals with symptoms attributed to mTBI, a description and characterization of their dizziness
(e.g., vertigo, lightheadedness, syncope, disequilibrium, confusion), temporal pattern (e.g., seconds,
minutes, hours, days), and symptom-provoking activities (e.g., rolling over in bed, bending over, head
movement) provides valuable information in establishing a working differential diagnosis. Primary care
assessment for vestibular disorders should be done before referring for further vestibular examination
and rehabilitation. Observation and patient interview are key elements to the examination and often
guide the clinician in determining the plan of care. Evaluation should include a thorough examination of
the following:
· Neurologic function
· Orthostatics
· Vision (acuity, monocular confrontation fields, pupils, eye movements, nystagmus)
· Auditory (hearing screen, otoscopic exam)
· Sensory (sharp touch, light touch, proprioception, vibration)
· Motor (strength, coordination)
· Cervical (range of motion)
· Vestibular (static and dynamic visual acuity, positional testing)
Evaluation of functional activities should include sitting and standing balance (e.g., Romberg with eyes
open/closed, single-leg stance) and gait (e.g., walking, tandem walking, walking with head turns, and
whole-body turning). Once the initial assessment is completed and other causes are eliminated
(e.g., vertebral basilar insufficiency, orthostatic hypotension, polypharmacy), referral to a vestibular
rehabilitation specialist (i.e., physical therapy or occupational therapy) is recommended for symptom
management.
2. Medication Review
A detailed medication history is warranted as numerous medications include dizziness as a potential side
effect. The following classes of medications are particularly important to consider: stimulants,
benzodiazepines, tricyclics, monoamine oxidase inhibitors, tetracyclics, neuroleptics, anticonvulsants,
selective serotonin agonists, beta blockers, and cholinesterase inhibitors. The temporal relationship to the
onset of dizziness and the initiation and dosing of these medications should be investigated.
c. Treatment
1. Pharmacologic Treatment
Initiating vestibular suppressants for dizziness may delay central compensation or promote
counterproductive compensation;(7, 8) and, while vestibular suppressants may be helpful during the acute
period of several vestibular disorders, they are not recommended after concussion.(9) Medications should
only be considered if symptoms are severe enough to significantly limit functional activities. Trials of
medications should be brief (optimally less than a week), and particular attention should be paid to dosing
June 2021 Page 16 of 30VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
and titration due to the effects on arousal, cognition, and memory, and the potential addictive qualities of
these medications.(10) Meclizine is the preferred agent, followed by scopolamine and dimenhydrinate.
The use of clonazepam, diazepam, or lorazepam is discouraged due to the sedating and addictive qualities
of those agents.
2. Non-Pharmacologic Treatment
Non-pharmacologic interventions for posttraumatic dizziness may be useful as an alternative to or in
conjunction with pharmacotherapies, although the effectiveness of such interventions is not fully
established with mTBI.(11) The efficacy of vestibular and balance rehabilitation has been shown in
different, non-TBI populations.(12-14) Patients with vestibular disorders who received customized
programs showed greater improvement than those who received generic exercises.(13) Studies utilizing
vestibular exercises have shown up to an 85% success rate in reducing symptoms and improving function
in the population with peripheral vestibular disorders.(13, 15)
With mTBI, recovery of vestibular lesions is often limited or protracted due to the coexistence of central or
psychological disorders.(16) Evidence is limited regarding the benefits of specific vestibular exercises for
patients with a history of mTBI and psychological co-occurring symptoms.
Knowledge of canalith repositioning and liberatory maneuvers for the treatment of benign paroxysmal
positional vertigo (BPPV) is beneficial for primary care physicians.(17) Clinicians should perform the Dix-
Hallpike and supine roll tests to assess for BPPV; radiographic imaging, vestibular testing, and routinely
treating BPPV with vestibular suppressant medications is not recommended.(18) In addition, patients with
history and clinical examination consistent with BPPV, whose symptoms do not fully resolve after one trial
of a canalith repositioning maneuver, may also be sent to a vestibular rehabilitation therapist for further
specialized BPPV assessment and treatment.
In cases of persistent dizziness and disequilibrium, a vestibular rehabilitation therapist may also be utilized
to execute a more comprehensive vestibular and balance evaluation and treatment program. The types of
specialized assessment tools, maneuvers, and exercises to treat dizziness and disequilibrium are beyond
the scope of this guideline. Patients with central, functional, and psychological disorders need a
coordinated team effort to address the underlying impairments and activity limitations in order to
maximize the outcome of vestibular rehabilitation.
If an individual appears to be at fall risk due to symptoms of dizziness and disequilibrium, referral for
home evaluation for adaptive equipment should also be considered as a compensatory strategy to limit
further injury.
The Office of the Surgeon General (OTSG) Army Toolkit and TBICoE may also provide guidance regarding
symptoms of dizziness and vestibular rehabilitation.g While these resources may assist PCPs, the Work
Group did not review the information contained in these documents. (See Appendix J in the full VA/DoD
mTBI CPG.)
g Hearing Center of Excellence. Available at: https://hearing.health.mil/For-Providers/Standards-and-Clinical-Practice-
Guidelines/COMMON-DIZZINESS-AND-BALANCE-DISORDERS-IN-MILITARY-POPULATIONS
June 2021 Page 17 of 30VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
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G. Visual Symptoms
a. Background
Vision symptoms, including sensitivity to light, eye fatigue, difficulty focusing, and blurry vision occur
acutely in some individuals who sustain mTBI. Most vision symptoms resolve within minutes or hours;
however, for those with persistent difficulties, targeted assessments to guide symptom management
during the first few weeks after mTBI are most effective.
Primary care providers (PCPs) need to be aware of reasons for an urgent referral to an eye care provider,
including: vision loss or decline, diplopia, abnormal pupils, abnormal external eye exam (e.g., evidence of
infection or hemorrhage), abnormal visual behavior (e.g., unexpectedly bumping into things), abnormal
eye movements (e.g., nystagmus), or acute ocular symptoms (e.g., evidence of trauma, severe eye pain,
flashes and/or floaters, severe photophobia). If visual symptoms persist and impact daily function,
providers should refer patients to optometry, ophthalmology, neuro-ophthalmology, neurology, and/or
vision rehabilitation team.
Higher-order cognitive symptoms (e.g., visual-spatial issues, spatial bias) may be mistaken by either the
Veteran, or the clinician, for ocular or vision issues, especially because these cognitive symptoms are
usually associated with unawareness of deficit (anosognosia). Occupational therapy vision assessment, or
behavioral neurology assessment, may be very helpful in ruling out these symptoms.
b. Assessment and Treatment
In response to persistent vision symptoms, primary care clinicians or others should inquire about how the
vision impairment has impacted the individual’s daily functioning by asking questions such as, “how have
your vision problems impacted school or work such as reading and/or using a computer?” If functional
complaints or impairments are evident, the clinician should proceed with a basic eye/vision exam which
should include visual acuity (distant and near), monocular confrontational fields, pupils (size/equality/
response), eye movements, an external exam (direct illumination of anterior segment), and nystagmus
(primary position and gaze evoked). The clinician should also perform a slit lamp exam, if available.
Medications should be evaluated. Drugs that may be associated with vision symptoms include
antihistamines, anticholinergics, digitalis derivatives, antimalarial drugs, corticosteroids, erectile
dysfunction drugs, phenothiazines, chlorpromazine, indomethacin, and others. Other co-occurring
symptoms (e.g., migraines, sleep disturbances, chronic pain, mood disorders, PTSD) may be contributing
factors or the source of the vision dysfunction.
If the vision problem is impacting function over time, a referral to a specialist trained in specialized
oculomotor assessment (e.g., neuro-ophthalmology, polytrauma blind rehabilitation outpatient specialist,
low vision therapist, occupational therapist) should be made to complete a vision screen and functional
assessment. If indicated, an eye care provider can complete a comprehensive vision assessment and
together with the rehabilitation team can develop a treatment intervention to address the individual’s
visual complaints and functional deficits.
The types of specialized vision rehabilitation assessment tools and interventions (e.g., vision exercises) to
address visual dysfunction related to mTBI are beyond the scope of this guideline. Patients benefit from a
coordinated team effort to address the underlying impairments and maximize vision rehabilitation.
June 2021 Page 18 of 30VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
Additional resources to support vision care and vision disorders after mTBI can be found through the
TBICoEh and Vision Center of Excellencei websites.
H. Fatigue
a. Background
Fatigue is one of the most common symptoms following mTBI. Fatigue can be a primary effect related to
central nervous system dysfunction or a secondary effect of common coexisting disorders in mTBI (e.g.,
depression, chronic pain, sleep disturbances). Medications, substance use, and unhealthy lifestyle habits
may also contribute to fatigue.
b. Assessment and Treatment
A detailed pre- and post-injury history of physical activity, cognitive function, and mental health is
important to determine the effects of fatigue in temporal relation to the injury. It is important to review
current medications and supplements for possible side effects. Multiple self-assessment scales for fatigue
exist, many of which have been studied in other populations. Common fatigue assessment tools used in
TBI include the Multidimensional Assessment of Fatigue (MAF), Fatigue Impact Scale (FIS), and the Fatigue
Assessment Instrument (FAI). Objective testing (e.g., laboratory evaluation), to exclude other medical
conditions contributing to fatigue, should be considered when clinically indicated.
Education is an important component in the management of fatigue. Educational efforts should be
focused on the modification of lifestyle factors including a healthy diet, regular exercise, and sleep
hygiene. Cognitive behavioral therapy may be a useful management approach for post-traumatic
fatigue. Exercise routines should be individualized to maximize benefit and promote a proper ratio of
activity and rest.
I. Sleep Disturbance
a. Background
Sleep disturbance is a common complaint of individuals with a history of mTBI.(19) Assessment and
treatment of sleep disturbances is similar to individuals without a history of mTBI. In an individual with a
history of mTBI, co-occurring conditions (e.g., anxiety, depression, PTSD, chronic pain, headache) can
complicate the clinical picture, as many of these conditions can also negatively impact sleep.
See the VA/DoD 2019 CPG on the Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea
for more detailed recommendations on assessment and treatment of chronic complaints for sleep
disturbance.j
h Available at: https://health.mil/About-MHS/OASDHA/Defense-Health-Agency/Research-and-Development/Traumatic-Brain-
Injury-Center-of-Excellence/Provider-Resources
i Available at: https://vce.health.mil/Clinicians-and-Researchers/Clinical-Practice-Recommendations
j See the VA/DoD Clinical Practice Guideline for Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea.
Available at: https://www.healthquality.va.gov/guidelines/CD/insomnia/index.asp
June 2021 Page 19 of 30VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
b. Assessment
Assessing individuals with reported sleep disturbance and its underlying causes is an essential component
of the clinical work-up. It is important to attribute symptoms correctly and to identify and treat any co-
occurring conditions.
c. Treatment
Treatment will be dependent upon specific sleep disorder diagnosis and etiological cause. For chronic
insomnia, the use of non-pharmacologic therapies should be considered a first-line treatment.
Pharmacologic treatment of sleep disturbance following mTBI may be complex. For all pharmacologic
interventions, providers should weigh the risk-benefit profiles, including toxicity and abuse potential.
J. Cognitive Symptoms
a. Background
Cognitive symptoms are common after mTBI. While symptoms improve within days to several weeks in
most situations, cognitive problems in attention, thinking speed, memory, and executive functions may
persist for several months or years for some. For those reporting cognitive symptoms for more than
30 days following mTBI, a time-limited trial of cognitive rehabilitation with a focus on psychoeducation and
strategies for daily function may facilitate recovery. Persons with persistent or late-emerging cognitive
symptoms (e.g., months to years following TBI) may benefit from an integrated and holistic approach to
cognitive symptom management, particularly when co-occurring conditions and associated refractory
symptoms are present.(20) Because problems with speech and language or spatial function (e.g., spatial
neglect) can be mistaken for problems with memory, concentration, or executive function, specific
screening for these issues, especially in Veterans with co-occurring stroke risk factors, is important.
Since 2009, the term “polytrauma triad” has been used to describe the higher rate of chronic pain and
mental health disorders in those with a history of military-related TBI.(21) These factors can impact daily
functioning across multiple domains (i.e., cognitive, emotional, behavioral) and require referral for
appropriate management to maximize effectiveness of cognitive rehabilitation. Recent evidence
demonstrating that physical (e.g., pain, headache, fatigue),(22) psychological (e.g., PTSD, anxiety,
depression),(22) and sleep conditions (23, 24) are significant contributors to cognitive symptoms
following mTBI further supports the need for integrated, interdisciplinary management of functional
cognitive complaints, including cognitive rehabilitation, particularly in patients with chronic or late-
emerging symptoms.
In 2020, Belanger et al. reported “self-efficacy” (i.e., one’s personal perception of one’s abilities and
capabilities) as the most potent predictor of cognitive rehabilitation response in a study of Service
Members and Veterans following mTBI.(25) As such, developing a therapeutic alliance, establishing
positive but realistic expectations, and providing quick wins early in treatment may be critical components
of effective, clinician-directed, cognitive rehabilitation. Psychoeducation that is centered on validation of
symptoms and understanding their impact on function should include information about the potential
contributions of coexisting conditions, and medication side effects, on cognitive dysfunction.
June 2021 Page 20 of 30VA/DoD Clinical Practice Guideline for the Management and Rehabilitation of
Post-Acute Mild Traumatic Brain Injury
b. Clinical Guidance
A comprehensive evaluation that combines objective, self-report, and ecologically-relevant measures may
be necessary to capture the functional impact of cognitive symptoms following mTBI.(26) Practices such as
motivational interviewing (27) and goal attainment scaling (28, 29) have been shown to facilitate the
development of meaningful treatment goals and plans that align with patient values, preferences,
functional needs, and limitations. Assessments and guided interventions that promote active engagement
in the treatment process and self-management techniques empower patients to co-manage their recovery
and contribute to self-efficacy. Short-term trials of evidence-based cognitive rehabilitation (e.g., 4 – 6
sessions) may provide sufficient information to determine potential benefit from further cognitive
rehabilitation. Prolonged treatment trials that are not resulting in improved activity participation, and that
perpetuate dependence and a “sick role,” are strongly discouraged.
Compensatory training as an individualized, functional intervention can involve adaptive strategies such as
environmental modifications to facilitate attention and establishing and practicing new techniques
(e.g., organization, note-taking) to support daily functioning, work, and school activities. Compensatory
strategy training requires selection of appropriate targets, building skills based on prior knowledge, and
training of sufficient intensity and complexity to ensure transfer of learned skills and habits to everyday
situations.(30) Cognitive assistive technologies may range from a wristwatch with an alarm function to a
multi-function device (e.g., smartphone, tablet). Familiar and commercially available devices are easier to
learn and may lead to less abandonment than customized devices. Successful long-term utilization of
compensatory strategies and devices ultimately requires specialized evaluation to select the appropriate
technique or device (for the person and the situation) and sufficient practice in meaningful, real-life
contexts.(31, 32)
Treatment approaches for executive functions that promote self-reflection and self-regulation are
suggested to support generalization of treatment gains to community-based activities that lead to
functional independence. Mobile applications (e.g., Concussion Coach, PTSD Coach, CBTi) may be
beneficial when used in support of a comprehensive treatment approach focused on self-management
and real-world benefit. For example, assistive devices and apps for self-management, self-advocacy, health
monitoring or journaling, can increase self-awareness and reduce the impact of memory dysfunction on
accurate symptom self-monitoring and reporting to medical providers.
K. Persistent Pain
(See also discussion of Headache.)
a. Background
Approximately 40-50% of individuals with a history of mTBI may experience chronic pain.(33) Pain
management is similar to individuals without a history of mTBI. However, in individuals with a history of
mTBI, the complaint of chronic pain is sometimes interwoven with co-occurring conditions such as sleep
disorders, anxiety, MDD, or PTSD.
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